SCQ. Self-Completed Questionnaire

Self-Completed Questionnaire Module of J-Star

item label type description
SCQ1 Question Please select the item that most accurately describes your overall current health. (Circle only one.)
SCQ2_1 Question Can you go out by yourself, using buses or trains?
SCQ2_2 Question Can you shop for daily needs?
SCQ2_3 Question Can you draw your own bath at night?
SCQ2_4 Question Can you pay your bills?
SCQ2_5 Question Can you make deposits and withdrawals from your bank or postal account?
SCQ2_6 Question Can you fill out documentation for your pension, etc.?
SCQ2_7 Question Do you read a newspaper?
SCQ2_8 Question Do you read books or magazines?
SCQ2_9 Question Are you interested in articles or programs about health?
SCQ2_10 Question Do you visit the homes of friends?
SCQ2_11 Question Do you give advice to family or friends?
SCQ2_12 Question Can you visit sick people?
SCQ2_13 Question Do you ever talk to young people?
SCQ2_14 Question Do you use the telephone by yourself?
SCQ2_15 Question Do you take medicine by yourself?
SCQ3 Question How much time you spend walking, including shopping, going to work or going out.
SCQ4 Question Do you regularly use tobacco, or did you use it in the past? (Circle only one answer.)
SCQ4_1 Question At about what age did you begin smoking regularly?
SCQ4_2 Question About how many cigarettes do you smoke per day (or did you used to smoke per day)? (Answer in number of cigarettes or number of packs.)
SCQ4_3 Question At about what age did you quit smoking?
SCQ5 Question We would now like to ask about your alcohol consumption. In the past six months, about how frequently did you drink alcohol (including beer, mixed drinks, whiskey, shochu, sake, or wine)?
SCQ5_1 Question On days when you drank, what and how much did you drink? If you drank more than one kind of drink, please count the total you drank per day.
SCQ6 Question Are you currently concerned about your health?
SCQ7 Question Are you confident that you will be healthy three years from now?
SCQ8_1 Question Felt unusual in some way 1 2 3 4
SCQ8_2 Question Had no appetite
SCQ8_3 Question Felt depressed and could not be consoled by family or friends
SCQ8_4 Question Felt I could do anything a normal person could do
SCQ8_5 Question Could not concentrate on what I was doing
SCQ8_6 Question Felt depressed
SCQ8_7 Question Something that is normally effortless was difficult to do
SCQ8_8 Question Felt the future was bright
SCQ8_9 Question Felt that my life so far has been a failure
SCQ8_10 Question Felt frightened
SCQ8_11 Question Could not sleep well
SCQ8_12 Question Felt happy
SCQ8_13 Question Felt more taciturn than usual
SCQ8_14 Question Felt lonely
SCQ8_15 Question People around me seemed cold to me
SCQ8_16 Question Felt happy
SCQ8_17 Question Cried or felt like crying
SCQ8_18 Question Felt sad.
SCQ8_19 Question Felt that people around me disliked me
SCQ8_20 Question Didn't feel like doing anything
SCQ9 Question Are you satisfied or unsatisfied with your current life? (Circle only one answer.)
SCQ10_1 Question Spouse (or common-law spouse)
SCQ10_2 Question Relatives living in your house other than spouse
SCQ10_3 Question Children or other close relatives not living with you
SCQ10_4 Question Friends, acquaintances, neighbors, etc.
SCQ11_1 Question Spouse (or common-law spouse)
SCQ11_2 Question Relatives living in your house other than spouse
SCQ11_3 Question Children or other close relatives not living with you
SCQ11_4 Question Friends, acquaintances, neighbors, etc
SCQ12_1 Question Spouse (or common-law spouse)
SCQ12_2 Question Relatives living in your house other than spouse
SCQ12_3 Question Children or other close relatives not living with you
SCQ12_4 Question Friends, acquaintances, neighbors, etc
SCQ13_1 Question Spouse (or common-law spouse)
SCQ13_2 Question Relatives living in your house other than spouse
SCQ13_3 Question Children or other close relatives not living with you
SCQ13_4 Question Friends, acquaintances, neighbors, etc
SCQ14_1 Question Care of children
SCQ14_2 Question Make income
SCQ14_3 Question Prepare meals, clean house, do laundry
SCQ14_4 Question Care of older relatives
SCQ14_5 Question Keep household accounts
SCQ14_6 Question Decide on major purchases
SCQ15 Question How satisfied are you overall with your relationship with your spouse?
SCQ16_1 Question Men should work outside the home and women inside the home
SCQ16_2 Question Boys and girls should be raised differently
SCQ16_3 Question Women are more suited than men for housework and childcare
SCQ17_1 Question Responsibility for social needs of elderly
SCQ17_2 Question Responsibility for medical care of elderly
SCQ18_1 Question Pharmacy and medical care facilities nearby
SCQ18_2 Question Shops selling groceries and daily needs nearby
SCQ18_3 Question Park where you can walk and exercise safely nearby
SCQ18_4 Question Train station or bus stop nearby
SCQ18_5 Question There are pollution or noise problems
SCQ18_6 Question There are concerns about public order such as vandalism or crime
SCQ18_7 Question There is a location nearby to meet with friends
SCQ19_1 Question Do you think you can trust most of them?
SCQ19_2 Question Do you think that others would take advantage of you given the opportunity?
SCQ19_3 Question Do you think most of them try to help others?
SCQ20 Question When you thought of the area “near you” in the previous question, which of the following came to your mind? (Circle only one answer.)
SCQ21_1 Question About how much time per day did you spend on the following activities past monthon weekdays? Commuting
SCQ21_2 Question Work
SCQ21_3 Question Housework, shopping for daily needs, caring for children or grandchildren
SCQ21_4 Question Caring for parent, spouse, or family member
SCQ21_5 Question Exercise, sports, walking
SCQ21_6 Question Studying/learning
SCQ21_7 Question Community meetings, religious activities, political activities
SCQ21_8 Question Hobbies, amusements, socializing
SCQ21_9 Question Resting, relaxing
SCQ22_1 Question We would now like to ask about your friendships. Context in which you met of male friends Know from childhood or school days
SCQ22_2 Question Know from work
SCQ22_3 Question Know from hobby or volunteer activity
SCQ22_4 Question Know through spouse or children
SCQ22_5 Question Met through friend after graduating from schoo
SCQ22_6 Question Live nearby
SCQ22_7 Question Other: (Describe: )
SCQ22_8 Question How many male friends in all? Know from childhood or school days
SCQ22_9 Question Know from work
SCQ22_10 Question Know from hobby or volunteer activity
SCQ22_11 Question Know through spouse or children
SCQ22_12 Question Met through friend after graduating from school
SCQ22_13 Question Live nearby
SCQ22_14 Question Other: (Describe: )
SCQ22_15 Question Number of male friends with whom you would share concerns, etc.Know from childhood or school days
SCQ22_16 Question Know from work
SCQ22_17 Question Know from hobby or volunteer activity
SCQ22_18 Question Know through spouse or children
SCQ22_19 Question Met through friend after graduating from schoo
SCQ22_20 Question Live nearby
SCQ22_21 Question Other: (Describe: )
SCQ22_22 Question Number of male friends you could ask for help if you were sick, injured or hadsome other problem.Know from childhood or school days
SCQ12_23 Question Know from work
SCQ22_24 Question Know from hobby or volunteer activity
SCQ12_25 Question Know through spouse or children
SCQ22_26 Question Met through friend after graduating from school
SCQ22_27 Question Live nearby
SCQ22_28 Question Other: (Describe: )
SCQ22_29 Question Other: (Describe: )
SCQ22_30 Question Context in which you met of female friendsKnow from childhood or school days
SCQ22_31 Question Know from work
SCQ22_32 Question Know from hobby or volunteer activity
SCQ22_33 Question Know through spouse or children
SCQ22_34 Question Met through friend after graduating from school
SCQ22_35 Question Other: (Describe: )
SCQ22_36 Question How many female friends in all? Know from childhood or school days
SCQ22_37 Question Know from work
SCQ22_38 Question Know from hobby or volunteer activity
SCQ22_39 Question Know through spouse or children
SCQ22_40 Question Met through friend after graduating from school
SCQ22_41 Question Live nearby
SCQ22_42 Question Other: (Describe: )
SCQ22_43 Question Number of female friends with whom you would share concerns, etc. Know from childhood or school days
SCQ22_44 Question Know from work
SCQ22_45 Question Know from hobby or volunteer activity
SCQ22_46 Question Know through spouse or children
SCQ22_47 Question Met through friend after graduating from schoo
SCQ22_48 Question Live nearby
SCQ22_49 Question Other: (Describe: )
SCQ22_50 Question Number of female friends you could ask for help if you were sick, injured or hadsome other problem. Know from childhood or school days
SCQ22_51 Question Know from work
SCQ22_52 Question Know from hobby or volunteer activity
SCQ22_53 Question Know through spouse or children
SCQ22_54 Question Met through friend after graduating from school
SCQ22_55 Question Live nearby
SCQ22_56 Question Other: (Describe: )
SCQ22_57 Question Other: (Describe: )
SCQ23 Question Overall, are you satisfied with your current friendships?
SCQ24 Question In the past month, have you done non-work activities with anyone other thanfamily or friends?
SCQ24_1 Question What kind of activity was it? Please select all applicable answers.
SCQ24_2 Question Enter the number of the activity above you engaged in most frequently:
SCQ24_3 Question About how often did you engage in the activity you named in question 24-2? (Circle only one answer.)
SCQ25 Question We would now like to ask about your contributions to and support of charitable enterprises. In the past year, have you contributed to a charity? If so, about how much did you donate? A rough estimate is fine.
SCQ26 Question Do you manage your household finances together with your spouse (or common-law spouse), or separately?
SCQ27 Question About how much income did you have in the last year after taxes and social insurance deductions? Please include not only wages, but any income from pensions or financial assets (fixed-term savings, government bonds, etc.) or real estate in your name.
SCQ28 Question We would now like to ask about any taxes or social insurance premiums paid in your own name. In the past year, did you pay any income tax, resident tax, business tax, fixed-asset tax, automobile tax, inheritance tax, or social insurance premiums
SCQ28_1 Question Only for respondents who answered “Yes” to question 28. In the past year, about how much did you pay all together? If you can, circle any items you paid and state the amount. If you can distinguish between taxes and social insurance deductions, please do
SCQ29 Question We would now like to ask about your spouse’s income. About how much income did your spouse have in the last year after taxes and social insurance deductions? Please include not only wages, but any income from pensions or financial assets (fixed-term savin
SCQ30 Question We would now like to ask about any taxes or social insurance premiums paid in your spouse’s name. In the past year, did your spouse pay any income tax, resident tax, business tax, fixed-asset tax, automobile tax, inheritance tax, or social insurance premi
SCQ30_1 Question Only for respondents who answered “Yes” to question 30. In the past year, about how much did your spouse pay all together? If you can, circle any items your spouse paid and state the amount. If you can distinguish between taxes and social insurance deduc
SCQ31 Question Do you manage your assets together with your spouse (or common-law spouse) or separately?
SCQ32 Question Do you have savings in your own name? Please include regular bank or postal savings accounts, and fixed-term and fixed-amount accounts (including credit unions, credit societies, agricultural cooperatives, credit banks, etc.).
SCQ33 Question Do you own securities in your own name in an investment trust (MMF, medium-term government bond fund, foreign investment trust, etc.), discount bank debentures, wide funds, government bonds, corporate securities, etc.?
SCQ33_1 Question This question is only for respondents who answered “Yes” to question 33. About how much do you have in those accounts?
SCQ34 Question Do you own in your own name securities that can be traded through an investment company?
SCQ34_1 Question This question is only for respondents who answered “Yes” to question 34. If you sold all those securities today, about how much could you get for them?
SCQ35 Question Does your spouse have savings in his or her own name? Please include regular bank or postal savings accounts, and fixed-term and fixed-amount accounts (including credit unions, credit societies, agricultural cooperatives, credit banks, etc.).
SCQ35_1 Question This question is only for respondents who answered “Yes” to question 35. About how much does your spouse have in those accounts?
SCQ36 Question Does your spouse own securities in his or her own name in an investment trust (MMF, medium-term government bond fund, foreign investment trust, etc.), discount bank debentures, wide funds, government bonds, corporate securities, etc.?
SCQ36_1 Question This question is only for respondents who answered “Yes” to question 36. About how much does your spouse have in those accounts?
SCQ37 Question Does your spouse own in his or her own name securities that can be traded through an investment company?
SCQ37_1 Question This question is only for respondents who answered “Yes” to question 37. If your spouse sold all those securities today, about how much could he or she get for them?
SCQ38 Question This concludes the questionnaire. Did you answer this questionnaire on your own, or with the assistance of a family member or caregiver? (Circle only one answer.)
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